Gordon I. Groh

Management of traumatic sternoclavicular joint injuries.

&NA; Traumatic sternoclavicular joint injuries account for <3% of all traumatic joint injuries. Proper recognition and treatment are vital because these injuries may be life threatening. Injuries are classified according to patient age, severity, and, in the setting of dislocation, the direction of the medial clavicle. Anterior injuries are far more common than posterior injuries. Posterior dislocation may be associated with complications such as dyspnea, dysphagia, cyanosis, and swelling of the ipsilateral extremity as well as paresthesia associated with compression of the trachea, esophagus, or great vessels. These life‐threatening complications may present at the time of injury but can develop later, as well. Radiography has been largely supplanted by CT for evaluation of this injury, although an oblique view developed by Wirth and Rockwood is useful in evaluating isolated sternoclavicular injury. MRI is useful in differentiating physeal injury from sternoclavicular dislocation in patients aged <23 years.

Complications rates, reoperation rates, and the learning curve in reverse shoulder arthroplasty

BACKGROUND Reverse shoulder arthroplasty (RSA) has ushered a new era in shoulder surgery. However, the results of RSA also described the complication rates associated with the procedure as inordinate and a learning curve associated with the incidence of complications. METHODS The records of 112 patients who underwent 114 RSA procedures by the senior author (G.I.G.) were reviewed for complications related to a RSA. Of these, 93 RSA procedures were the primary treatment for the shoulder, and 21 were revisions. RESULTS The total complication rate for the entire group was 7%. Complications included 3 periprosthetic fractures, 3 hematomas, 1 acromion fracture, and 1 deep infection. The complication rate was 19% in the revision RSA group and 4.3% in the primary RSA group (P ≤ .02). Complication rates in the initial RSA patients in this series did not differ from the final procedures in this series (P = .96). The total reoperation rate was 5.3%, and was 19% in the revision RSA group vs 2.2% in the primary RSA group (P ≤ .02). CONCLUSION Complications and reoperations associated with a RSA, although significant, occurred at much lower rate than in previous reports. This series demonstrates a significant difference in complication rates and reoperation rates between primary and revision RSA. Revision RSA complications and reoperations were far more common than in primary RSA procedures. No evidence of a learning curve related to surgical experience was demonstrated in this series.

Treatment of traumatic posterior sternoclavicular dislocations

BACKGROUND Traumatic posterior sternoclavicular joint injuries are rare, but complications are common and include brachial plexus and vascular injury, esophageal rupture, and death. MATERIALS AND METHODS The records of 21 patients treated at our institution for a posterior sternoclavicular injury were reviewed. All patients underwent a trial of closed reduction, which was effective in 8 patients (group I). The remaining 13 patients were treated with open reduction and sternoclavicular joint reconstruction (group II). RESULTS Closed reduction was more likely to be successful (P < .05) in dislocations treated within 10 days of injury. Patients were evaluated by use of the University of California, Los Angeles rating scale. Overall, 18 of 21 patients were graded as good or excellent. Patients treated with either open or closed reduction as their definitive management compared favorably in terms of ratings for pain, strength, and motion. CONCLUSION Our experience suggests that closed reduction compares favorably with open reduction. Of patients treated, 38% required only closed reduction as their definitive treatment. In this series early closed reduction was successful and obviated the risks of surgery. Patients who in whom closed reduction failed obtained good results with operative treatment aimed at reconstruction of the costoclavicular ligaments.

Capsulorrhaphy through an anterior approach for the treatment of atraumatic posterior glenohumeral instability with multidirectional laxity of the shoulder

Between June 1983 and March 1992, we performed a capsular reconstruction procedure through an anterior approach in ten patients (ten shoulders) who had multidirectional laxity of the shoulder and symptomatic atraumatic posterior glenohumeral instability. The procedure included closure of the capsule in the rotator interval and imbrication of the anterior, inferior, and posteroinferior aspects of the capsule by a double-breasting technique that decreases the overall capsular volume. The mean duration of follow-up was sixty months (range, twenty-four to 103 months). According to the system of Rowe and Zarins, the result was graded as excellent for five shoulders, good for four, and poor for one. On the basis of our results, we recommend capsular reconstruction through an anterior approach only in patients who have persistent multidirectional laxity and symptomatic atraumatic posterior instability of the shoulder despite participation in an intensive rehabilitation program.

Treatment of Complications of Shoulder Arthrodesis

A reconstructive osteotomy was performed to correct symptomatic malposition after arthrodesis of the shoulder in nine of fourteen patients who had complications related to the arthrodesis. The clinical position of the arm in relation to the trunk was determined with the method described by Rowe. Malposition was primarily the result of fusion in more than 15 degrees of either flexion or abduction, or both, coupled with improper rotation, defined as rotation of less than 40 degrees or more than 60 degrees. Reconstructive osteotomy eliminated pain and improved the ability of the patient to perform six activities of daily living. The complications necessitating operative treatment after the arthrodesis in the remaining five patients included failure of the arthrodesis site to unite (three patients), a wound hematoma at the iliac-crest donor site (one patient), and a superficial wound infection (one patient). Two additional complications—a fracture through a screw-hole in the humerus and a fracture distal to the internal fixation device—occurred after the reconstructive osteotomies for malposition. All of the complications resolved with treatment. Arthrodesis of the shoulder is a technically demanding procedure that can lead to serious complications that necessitate operative intervention. Careful attention to operative technique and to the position of the arthrodesis are essential.

Treatment of cysts of the acromioclavicular joint with shoulder hemiarthroplasty

A chronic cyst overlying the acromioclavicular joint was managed in four patients, between July 1988 and September 1991. All patients had had previous unsuccessful aspiration and excision of the cyst with recurrence. Each cyst was associated with a chronic, massive defect of the rotator cuff; superior migration of the humeral head; and degenerative osteoarthrosis of the glenohumeral joint. All patients had complained of pain and limitation of motion (mean forward elevation, 95 degrees; mean external rotation, 20 degrees; and mean internal rotation, to the spinous process of the second lumbar vertebra). All procedures consisted of a large-humeral-head hemiarthroplasty, with no operative treatment directed at the cyst or the acromioclavicular joint. At an average of twenty-seven months (range, fifteen to thirty-six months) after the operation, the patients were all pain-free and had not had a recurrence of the cyst. The average postoperative range of motion was 130 degrees of forward elevation, 30 degrees of external rotation, and internal rotation to the spinous process of the first lumbar vertebra.

Membrane Disordering Effects of Anesthetics Are Enhanced by Gangliosides

The effects of anesthetic drugs on lipid order were evaluated by the fluorescence polarization of the probe molecule, 1,6-diphenyl-1,3,5-hexatriene (DPH) incorporated into vesicles of dimyristoyl-phosphatidylcholine (DMPC) and DMPC with 10 mol% ganglioside (GDL2). Anesthetics (enflurane, chloroform, diethylether, pentobarbital, ethanol, butanol, hexanol) decreased the fluorescence polarization of DPH in vesicles of DMPC, but relatively large concentrations were required. Addition of gangliosides to DMPC enhanced the lipid disordering effects of anesthetics by several fold. The potencies of these anesthetics in decreasing fluorescence polarization of DPH in DMPC-ganglioside was well correlated with their potencies as anesthetics, and significant decreases in fluorescence polarization occurred at pharmacologically relevant concentrations. These results indicte that gangliosides can enhance the sensitivity of membrane lipids to the disordering effects of anesthetics and suggest that the large ganglioside content of the outer leaflet of the lipid bilayer of neuronal membranes may render this membrane region unusually sensitive to anesthetic agents.

Results of treatment of luxatio erecta (inferior shoulder dislocation)

HYPOTHESIS Traumatic inferior shoulder dislocation (luxatio erecta) injuries are rare, comprising less than 0.5% of all shoulder dislocations. Few cases have been reported, and the outcome of treatment has been ill defined. MATERIALS AND METHODS Between 1968 and 2000, 18 patients (20 shoulders) with luxatio erecta were evaluated at our institution. Two patients (2 shoulders) were lost to follow-up, leaving 16 patients (18 shoulders) for long-term follow-up (average, 9 years). Associated injuries included peripheral nerve injury, humeral fracture, acromial fracture, and rotator cuff tear. All patients were initially managed with closed reduction, which was successful in 9 shoulders. The remaining 9 shoulders required operative treatment. RESULTS Patients were evaluated with respected to pain, function, range of motion, strength, and patient satisfaction, according to the University of California at Los Angeles Rating Scale. Overall, 13 of the 16 patients were graded as good or excellent. Patients treated with closed reduction or operative treatment compared favorably in terms of improvements in ratings for pain, strength, motion, and the ability to perform work and sports. DISCUSSION Our experience suggests that treatment of luxatio erecta is largely successful, with good or excellent results obtained in 83% of the shoulders. Half of the patients evaluated, required only closed reduction as their definitive treatment. Operative treatment is typically indicated for associated displaced humeral head fractures or patients with recurrent instability. Recurrent instability appears to be more likely in patients with a previous history of dislocation. Associated neurologic or vascular injury did not affect the final outcome.

Results of revision from hemiarthroplasty to total shoulder arthroplasty utilizing modular component systems

BACKGROUND Hemiarthroplasty continues to be a common surgical treatment for glenohumeral arthritis. Unfortunately, some patients will develop painful glenoid arthrosis necessitating revision to total shoulder arthroplasty. Previously reported results of revision have demonstrated variability in results and difficulty. The purpose of this study was to determine the difficulty and results of revision from hemiarthroplasty to total shoulder arthroplasty utilizing modular component systems. MATERIALS AND METHODS Between 1995 and 2007, the authors identified 15 patients who underwent revision from hemiarthroplasty (HA) to total shoulder arthroplasty (TSA). Patients were assessed with the use of a UCLA score and a visual analogue scale at the time of the latest follow-up (mean, 40 months; range, 24-70 months). Radiographs were assessed for the presence of glenoid loosening, subluxation, and shift in component position. RESULTS Revision HA to TSA was significantly associated with pain relief (P < .01) as well as improvement in forward elevation from a mean of 91° to 141°. According to the UCLA scoring, the result was excellent in 9 shoulders, good in 5, and fair in 1. No instances of humeral or glenoid loosening were identified at the most recent examination. Only 2 stem revisions were necessary in this series of modular shoulder arthroplasties. CONCLUSION The data from this study suggest that revision of painful HA for glenoid arthrosis to TSA is a reliable procedure with good improvements in pain, range of motion, and function. With modular components, the complexity of the procedure is minimized. Poor results and the need for stem revision are infrequent occurrences.

Repair of soft tissue to bone using a biodegradable suture anchor

The medial collateral ligaments of 18 New Zealand rabbits were surgically detached from bone. In one knee, the ligament was repaired using a biodegradable suture anchor composed of a co-polymer of lactic and glycolic acid. The contralateral medial collateral ligament was not repaired. Animals were sacrificed at 4, 8, and 12 weeks after the operation, and the knee that had the ligament repair was compared with the contralateral control knee. All knees were tested manually tested for stability to valgus stress and then prepared for histologic examination. Medial collateral ligaments repaired using the biodegradable suture anchor demonstrated stability to valgus stress and anatomic healing at the bone-tendon junction. Resorption of the implant was virtually complete by 12 weeks. All specimens demonstrated less inflammatory reaction to the suture anchor than to the attached Vicryl suture. This contrasts with the control group, which was grossly unstable and demonstrated scarring in this nonanatomic position. These results demonstrate efficacy of this particular material of biodegradable implant and justify further investigative efforts.